The Adolescent-The Gynecologist's Dilemma

THE ROLE OF THE PHYSICIAN in caring for the adolescent female is one of the many problems encountered in medicine today. The basic confusion regarding services to minors stems from the lack of clear Federal legislation applicable to all 50 States' definitions of

minority. Compounding this morass is the individual physician's attitude toward providing services such as abortion or contraception for teenagers. Another important consideration must be predicated upon the interest and ability a gynecologist possesses in communicating with and directing treatment of minors. At present, there seems little likelihood of Federal legislation that defines minority or majority. Such definition is .a zealously guarded prerogative of the States. Consequently, incongruities regarding majority are apparent in most States.

New York Legislation on Majority As an example of the confusion in New York State, 21 is still the legal age of majority, but (a) females may obtain a marriage license at age 18, (b) voting privileges are permitted at age 18, (c) credit-card contracts may be entered into at age 18, (d) blood donations may be accepted without parental consent at age 18, (e) females need not have parental consent for abortion at age 17, and (f) examination and treatment for venereal disease may be instituted at any age without parentai consent. However, contraceptive services cannot be rendered to unemancipated females C Dr. Fiedler is director of medical services, Maternity, Infant Care-Family Planning Projects and assistant professor, Department of Obstetrics and Gynecology, New York Medical College, New York City. Tearsheet requests to Dolores E. Fiedler, MD, MICFP, 377 Broadway, New York, N.Y. 10013. 166 Public Health Reports

under 21 years of age without parental consent. With such a patchwork quilt of legal contradictions, and with the ever-present recognition of possible litigation citing malpractice, assault, and contributing to the delinquency of a minor, some gynecologists, understandably, feel compelled to withhold services until parental involvement is assured, despite a willingness to provide care for adolescents.

Views of Adolescents, Parents, Gynecologists The adolescent, living in this confusing permissive society and having no one to provide information, discussions, or services except her own often misinformed contemporaries, seeks help from those in the medical profession. Frequently, she seeks the gynecologist rather than a pediatrician. This is understandable. A girl entering adolescence no longer views herself as a child, and she consciously avoids anything or anyone that would retard her own concept of "growing up." Clearly then, the adolescent who actively solicits help and is denied it cannot be blamed totally for the consequences of her actions. The parental attitude must be considered next. If the law imposes upon them the responsibility of caring for a child until majority-socially, medically, educationally, and economically-then most parents take a jaundiced view of both the girl's sexual activity and medical services rendered the girl in nonemergency situations. Here, I am referring specifically to the area of birth control. Parents might construe provision of such services without their knowledge as promoting promiscuity rather than preventing pregnancy. In an emotionally charged situation, their attitudes also are understandable. The gynecologist is placed in an incongruous situation. The physician, recognizing the possible effect that providing or denying services to adolescents will have, must decide which action is appropriate. If he provides

DOLORES E. FIEDLER, MD, MPH

services, he is risking legal and parental disfavor. The physician must be prepared to defend his actions by subterfuge, presenting arguments such as attempting to detect venereal disease in a sexually active minor. But, how can venereal disease be prevented by his prescribing contraceptives for the minor female? Or, the gynecologist can offer as the rationale for his actions that it is wiser to help the adolescent prevent pregnancy than to help her with prenatal care or an abortion. If the gynecologist chooses to deny services to the adolescent, this choice may be the most pragmatic. But is it medically justifiable? If a physician abjectly denies services to a patient who seeks help, it is a violation of medical tradition and ethics. If he demands parental consent he protects himself, but he violates patient confidentiality. There are clinics in some communities that do provide contraceptive services to minors. These settings have an advantage in providing services that a private practitioner lacks. The private practitioner often has a clientele which includes family members of the adolescent, and again the dilemma surfaces. Unfortunately, in contraception also, the double standard applies. If the minor male desires a contraceptive, a medical prescription is unnecessary, because it is available at the drugstore. The minor female who desires a contraceptive method must visit a physician, or she is relegated to using one of the least effective methods of contraception-foam. The problem of adolescent pregnancy will not disappear-if anything, it is increasing. Sexual activity among minors is not diminishing, and no matter what one's attitude toward contemporary behavior may be, the consequences of this activity often make medical care a necessity. To continue to ignore the need for contraceptive services to the sexually active teenager who requests it is an indictment of the medical profession.

The dilemma is real, but the consequences following resolution of the dilemma may prove more disastrous than the dilemma itself. What can be done in such a situation?

Statement on Contraception The following statement was approved by the Executive Board of the American College of Obstetricians and Gynecologists in May 1971: 1. The unmarried female of any age whose sexual behavior exposes her to possible conception should have access to the most effective methods of contraception. 2. In order to accomplish this, the individual physician, whether working alone, in a group or in a clinic, should be free to exercise his best judgment in prescribing contraception and therefore, the legal barriers which restrict his freedom should be removed. 3. These restricting legal barriers should be removed even in the case of an unemancipated minor who refuses to involve her parents. A pregnancy should not be the price she has to pay for contraception. On the other hand, in counseling the patient, all possible efforts should be made to involve her parents. 4. The contraceptive services should be offered whenever possible in a broad spectrum counseling context which would include mental health and venereal disease. 5. Every effort should be made to include male partners in such services and counseling.

Conclusion Presently, the only course of action that seems feasible is to use the influence of various medical establishments to encourage various government agencies, Federal and State, to enact uniform legislation that permits physicians to provide services to anyone who requests care. This would give a physician some latitude in determining if he possesses the skills and ability to undertake the care of each patient. Without such action the dilemma remains, and all the inherent injustices perpetrated will continue to multiply to the detriment of physician, patient, and parent. March-April 1976, Vol. 91, No. 2 167

The adolescent--the gynecologist's dilemma.

The Adolescent-The Gynecologist's Dilemma THE ROLE OF THE PHYSICIAN in caring for the adolescent female is one of the many problems encountered in me...
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